Swapnil Khoche

Clinical outcomes in patients with isolated subsegmental pulmonary emboli diagnosed by multidetector CT pulmonary angiography.

INTRODUCTION CT Pulmonary Angiography has been shown to be equivalent to Ventilation/ Perfusion scanning in 3-month outcome studies, but it detects more pulmonary emboli. Isolated subsegmental pulmonary emboli are thought to account for some of the increase in diagnosis, but it is not known whether these emboli represent a harbinger for future thromboembolic events. The objective of this study was to determine the 3-month clinical outcomes of a cohort of patients diagnosed with isolated subsegmental pulmonary emboli. MATERIALS AND METHODS Review of 10,453 consecutive CTPA radiology reports over 74-month period since the implementation of Multidetector CT Pulmonary Angiography identified a cohort of 93 patients found to have acute pulmonary embolism isolated to subsegmental pulmonary arteries without other evidence of deep venous thrombosis at one institution. The study measured 3-month clinical outcomes (anticoagulation use, recurrence, death, hemorrhage) determined by review of records and telephone interviews with physicians. RESULTS Seventy-one patients (76%) were treated with anticoagulation and/or IVC filter, while 22 (24%) were observed without therapy. One patient (1/93, 1.05%; 95% CI: 0-6.6%) who was treated with anticoagulants and a vena caval filter had a recurrent subsegmental pulmonary embolus. No patients died of pulmonary embolism. There were 8 hemorrhages, including 5 (5.3%) major hemorrhages without any hemorrhage-related mortality. CONCLUSIONS Patients diagnosed with isolated subsegmental pulmonary emboli have favorable 3-month outcomes. Short-term prognosis for recurrent thromboembolism may be lower than the risk of adverse events with anticoagulation in patients at high risk of hemorrhage.

Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model.

BACKGROUND: Prehospital intubation does not result in a survival advantage in patients experiencing penetrating trauma, yet resistance to immediate transportation to facilitate access to definitive care remains. An animal model was developed to determine whether intubation provides a survival advantage during severe hemorrhagic shock. We hypothesized that intubation would not provide a survival advantage in potentially lethal hemorrhage. METHODS: After starting a propofol drip, Yorkshire pigs were intubated (n = 6) or given bag‐valve mask ventilation (n = 7) using 100% oxygen. The carotid artery was cannulated with a 14‐gauge catheter, and a Swan‐Ganz catheter was placed under fluoroscopy using a central venous introducer. After obtaining baseline hemodynamic and laboratory data, the animals were exsanguinated through the carotid line until death. The primary end point was time until death, while secondary end points included volume of blood shed, temperature, cardiac index, mean arterial pressure, lactic acid, base excess, and creatinine levels measured in 10‐minute intervals. RESULTS: There was no difference in time until death between the two groups (51.1 [2.5] minutes vs. 48.5 [2.4] minutes, p = 0.52). Intubated animals had greater volume of blood shed at 30 minutes (33.6 [4.4] mL/kg vs. 28.5 [4.3] mL/kg, p = 0.03), 40 minutes (41.7 [4.7] mL/kg vs. 34.9 [3.8] mL/kg, p = 0.04), and 50 minutes (49.2 [8.6] mL/kg vs. 40.2 [1.0] mL/kg, p = 0.001). In addition, the intubated animals were more hypothermic at 40 minutes (35.5°C [0.4°C] vs. 36.7°C [0.2°C], p = 0.01) and had higher lactate levels (2.4 [0.1] mmol/L vs. 1.8 [0.4] mmol/L, p = 0.04) at 10 minutes. Cardiac index (p = 0.66), mean arterial pressure (p = 0.69), base excess (p = 0.14), and creatinine levels (p = 0.37) were not different throughout the shock phase. CONCLUSION: Intubation does not convey a survival advantage in this model of severe hemorrhagic shock. Furthermore, intubation in the setting of severe hemorrhagic shock may result in a more profuse hemorrhage, worse hypothermia, and higher lactate when compared with bag‐valve mask ventilation.

Left Ventricular Systolic Function

The estimation of left ventricular systolic function, both qualitative and quantitative, remains essential to the perioperative management of the cardiovascular status of the surgical patient. As a result of its portability and versatility, echocardiography is now widely used for this purpose (Lang et al. in European Journal of Echocardiography 7(2):79–108, 2006 [1]). The spectrum of techniques for assessment of left ventricular systolic function is wide. This chapter provides an overview of some of the techniques that are essential for the basic echocardiographer and delineates the advantages, disadvantages, and pitfalls of each.

Heparin Induced Thrombocytopenia: A Novel Approach to Anticoagulation During Transcatheter Aortic Valve Replacement Utilizing Cangrelor

Transcatheter aortic valve replacement (TAVR) is a wellestablished therapy for patients with severe aortic stenosis who are at intermediate-high surgical risk. While the technical and procedural aspects of TAVR may vary, systemic anticoagulation with heparin or bivalirudin is universally used to reduce the risk of procedure-associated thromboembolic events. However, the optimal anticoagulation strategy for a patient with heparininduced thrombocytopenia (HIT) undergoing TAVR is unclear.

Perioperative Risk Factors Associated with Postoperative Unplanned Intubation Following Lung Resection

OBJECTIVE Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. DESIGN This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. SETTING Multi-institutional, prospective, surgical outcome-oriented database study. PARTICIPANTS Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. INTERVENTION None. MEASUREMENT AND MAIN RESULTS The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). CONCLUSIONS Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay.

The use of cangrelor with heparin for left ventricular assist device implantation in a patient with acute heparin-induced thrombocytopenia

BackgroundOptimal anticoagulation strategy for cardiopulmonary bypass (CPB) in end-stage heart failure patients with heparin-induced thrombocytopenia (HIT) requiring left ventricular assist device (LVAD) implantation remains uncertain. Presently, there are no large-scale randomized studies comparing outcomes of alternative anticoagulation strategies for CPB in this patient population. A novel antiplatelet agent – cangrelor, which is a potent P2Y12 inhibitor with robust antiplatelet efficacy, rapid reversibility, and measurable drug effect, has become available since 2015. Intraoperative anticoagulation for CPB using cangrelor with heparin has not been reported before.Case presentationWe report the case of a 47-year-old male with ischemic cardiomyopathy and acute HIT, who underwent an urgent LVAD implantation using cangrelor with heparin for anticoagulation on CPB. This novel strategy resulted in satisfactory anticoagulation for CPB without perioperative thromboembolic events or major bleeding requiring reoperation.ConclusionsCangrelor with heparin was an effective anticoagulation strategy for CPB in this critically ill patient with acute HIT requiring an urgent LVAD implantation. Further studies are warranted to evaluate its efficacy and replicability in other patients with acute or subacute HIT who require urgent cardiac surgery.

Hemodynamic Consequence of Hand Ventilation Versus Machine Ventilation During Transport After Cardiac Surgery

OBJECTIVES The hemodynamic consequences of ventilation of intubated patients during transport either by hand or using a transport ventilator have not been reported in patients after cardiac surgery. The authors hypothesized that bag-mask ventilation would alter end-tidal CO2 during transport and hemodynamic parameters in patients post-cardiac surgery. DESIGN A prospective, randomized trial. SETTING A university-affiliated tertiary care hospital. PARTICIPANTS Cardiac surgery patients. INTERVENTIONS Thirty-six patients were randomized to hand ventilation or machine ventilation. Hemodynamic variables including blood pressure, heart rate, peripheral saturation of oxygen, and end-tidal carbon dioxide (ETCO2) were measured in these patients prior to transport, every 2 minutes during transport and upon arrival in the intensive care unit (ICU). Pulmonary artery pressure (PA) pressures were measured at origin and at destination. MEASUREMENTS AND MAIN RESULTS Outcomes were changes from baseline in end-tidal CO2, hemodynamic changes from baseline and pulmonary artery pressure changes from origin to destination. The average transport time between the 2 groups was not different: 5 minutes for patients ventilated by hand and 5.47 minutes for patients ventilated with a transport ventilator (p = 0.369 by 2-sided t-test). The difference in all measured changes in ETCO2 between hand-ventilated and machine-ventilated patients during transport was 2.74 mmHg (p = 0.013). The difference between operating room and ICU ETCO2 from each cohort was 1.31 mmHg (p = 0.067). The difference in PAmean measured at origin and destination was 0.783 mmHg (p = 0.622). All other hemodynamic variables were not different during transport. CONCLUSIONS Hand ventilation during transport was associated with greater change from baseline of ETCO2 compared to machine ventilation during transport after cardiac surgery, but this did not translate into any difference in hemodynamic changes upon arrival in ICU. A hemodynamic benefit of machine transport ventilation to cardiac patients was not demonstrated.

Adult Congenital Heart Disease

The increasing number of patients with either uncorrected or repaired congenital cardiac lesions is on the rise, likely reflective of improvements in care and detection. With more patients surviving well into adulthood, they often present for non-cardiac surgery. Echocardiography remains central to the detection, and aids in both surgical and device-based correction. It can also provide important prognostic information and quantify the effects (from the lesion) on ventricular function, pulmonary and systemic flow, etc. It is important for the beginner and intermediate practitioner to familiarize himself/herself with basic lesions encountered in adulthood, the echocardiographic techniques used to further identify and evaluate each condition, and the associated conditions that need to be sought and ruled out.

Tuberculin syringes: a convenient way to administer intravenous anesthetics in neonates and infants.

echocardiographic monitoring during the procedure and careful manipulation of the catheter and guidewire through the whole procedure may be helpful (4). In our experience, monitoring the hemodynamics, return of the blood and postprocedural chest X-ray did not exclude the possibility of cardiac perforation. High index of suspicion should always be maintained and careful echocardiography with injection of contrast performed to prevent further catastrophic complication when the heart had been perforated. However, once it has happened, we suggest sternotomy for repair rather than conservative treatment. Ching-Chia Wang* Yung-Wei Chen† En-Ting Wu* Yin-Hsiu Chien* Wuh-Liang Hwu* Wen-Je Ko Shu-Chien Huang§ Department of *Pediatrics, Department of †Surgery, Yun-Lin Branch, Department of ‡Surgery and Department of §Traumatology, National Taiwan University Hospital, Taipei, Taiwan (email: dtsurg99@yahoo.com.tw)